Healthcare Provider Details

I. General information

NPI: 1114994589
Provider Name (Legal Business Name): EUGENE O GULLINGSRUD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2006
Last Update Date: 08/17/2023
Certification Date: 08/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10709 WAYZATA BLVD STE 200
MINNETONKA MN
55305-5509
US

IV. Provider business mailing address

8170 33RD AVE S
BLOOMINGTON MN
55425-4516
US

V. Phone/Fax

Practice location:
  • Phone: 952-888-5800
  • Fax: 952-567-6156
Mailing address:
  • Phone: 952-541-2800
  • Fax: 952-886-7015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number37798
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: